Costs are generated when a
patient, meets a health professional, (usually a doctor but in our modern
world, increasingly a nurse-clinician, a physician assistant or a non-MD
therapist), and decisions are made which generate claims and bills and
ultimately costs. An old saying in
medical management is that the most expensive medical instrument is the pen,
because doctors write orders with pens.
While today it may be the keyboard instead of the pen, the saying is
still true. This may appear obvious on
its face however when we think and write of health policies driving either savings
or increased costs, we must think about what happens between the patient and
the doctor. This joint decision making
may be thought of as an intricate dance that if performed well, results in a sacred
trust relationship. I fear that this
dance that doctors and patients take part in is changing and not necessarily
for the better.
I have a wonderful primary care
physician, who is very smart, and very caring and who was taught to be more
attuned to the population trends than I was taught to be, even though I have
spent the last thirty years of my life focused on just those population
needs. Needless to say he is
significantly younger than I am. More
than a week ago, I fell ill. I am fortunate
because I have medical knowledge, and I am married to the smartest physician I
know. The first few days of the illness,
I treated myself, with my wife’s advice.
After five days, my wife convinced me to call my PCP with an eye towards
getting an exam and some blood tests because we were both starting to get worried. I called my physician and he quite rightly
told me that I most likely had something that would get better on its own, and
that the best action at that time was to
wait. On that basis, he said, I probably
did not need to be seen and did not need blood tests. Because we have a close relationship, I kept
in touch by phone and a few days later he saw me in his office as I was still
sick. On exam he noted abnormal physical
findings and blood tests were found to be abnormal. We both saw that while
waiting had not hurt me, it was perhaps not the best approach in this instance
as it delayed treatment. It was, however
the right way to proceed from a statistical evidence based, population health point of view. I have to wonder if someone who did not have
as trusting a relationship with his or her doctor, would have stayed in as close
touch with the doctor as I did. If not,
they likely would have ended up with a more serious and more costly medical
condition.
The fact is, that even with my
sophistication or perhaps because of it, I needed that trusted, objective and
knowledgable confidant. I needed my
doctor to examine me and really hear my symptoms and my fears. I was scared and thinking the worst. No matter what, I felt better that I was
being cared for once I saw my doctor and was able to directly see his concern
for me and his thoughtfulness about my problem.
He has a concierge type of practice, together with three other
physicians (although they all function as solo practitioners with their own
nurse) and their practice fits into what is today considered to be a small
medical practice.
In a study just published on line in Health Affairs, Lawrence Casalino and his associates at Cornell Medical College found that, while it is assumed that large practices, often with team
based medical homes and quality of care controls in place, provide better care, smaller practices of
fewer than 9 physicians, had 27% fewer preventable hospital admissions with
practices of 1 to 3 physicians having 33% fewer preventable admissions. Physician owned practices also had fewer
preventable hospital admissions. The
authors postulated that this was perhaps due to easier access to the doctor who
was part of smaller practices. My theory
is that smaller, more personalized medical practices create more trust. When your doctor tells you to wait, you tend
to trust your doctor and wait rather than run to the Emergency Room and end up
admitted unnecessarily. While waiting, a
person cared for in a smaller practice will tend to stay in closer touch,
knowing that a call will allow one to speak to your trusted doctor or nurse rather
than be triaged by the nurse or doctor on call.
In our impatient society, one of
the hidden secrets of medicine is how time-based it is. Illnesses tend to follow, what is often
called in medicine, a natural history, and throughout much of the history of
medicine, the role of the physician was to know the natural history in order to
predict, for the patient and the family, what was likely to happen as the
physician’s ability to impact what was going to happen was limited. In our medically sophisticated world in which
there appears to be a drug and a procedure and a surgery for every ache and
pain, that physician’s art of prediction – of knowing the natural history and
thus being able to counsel a patient about not only what should be done, but
also if and when it should be done, is critical and is based on trust.
It is this trust that makes one
not only a physician but a healer. I
trust my doctor and for me, his judgment and his caring are critical to the
decisions I make. I still make my own
decisions, but his advice is necessary for me to make good decisions. Trust is
the key to the ability to time care appropriately which saves money and more
importantly, helps people avoid the risks of unnecessary care and the risks of
necessary care delayed.
In an unpublished work (privately
shared), Drs Saul Weiner and Simon Auster wrote about the need for physicians
to have healing relationships with their patients, in order to engender the
type of trust needed for medical care to be successful (and in case anyone has
not noticed – successful care is less expensive than unsuccessful care unless
of course the unsuccessful care results in very quick and efficient
death). They speak of the need for the
doctor and the patient to become one social unit, and the requirement that this
relationship happen over time with both the doctor and the patient sharing
parts of themselves in ways that creates vulnerabilities. They describe four characteristics of the
healing relationship.
- It cannot be scripted
- It evolves with a relationship over time
- The individuality of the physician, like the patient’s, is central to the direction the relationship takes
- It depends on trust or, in the initial phases, on the expectation of trust
This of course beings me back to
the dance between doctor and patient and the health care cost equation. The equation, just as a reminder is
Total Population Costs = Volume of Services X Unit Cost of
Service
The only way to decrease the
volume of services is to build relationships between health professionals and
patients that meet the four characteristics outlined by Weiner and Auster. When I was in medical school, I was taught
that my only focus should be the good of the patient whose care was entrusted
to me. The building and maintanence of
that sacred trust relationship was a
major part of the education that made me a doctor. In today’s world, we ask physicians to also
think about the health of populations and the reduction of the per capita costs
of health care as defined by the triple aim I spoke about in part 1 of this
series. My fear is that in trying to
make physicians more aware of the societal needs, we may inadvertently be changing
that focus and undermining the trust necessary to save money in health care the
right way.
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